It’s a day I remember well, I suspect that many of us remember it, or have a similar day we remember well… I was well into the fourth year of my residency program at the Medical College of Wisconsin (MCW) and was excited that I was getting to do a number of firsts. I was to meet staff from the Milwaukee County Behavioral Health Division’s Downtown Community Support Program (CSP), where I was doing my Community Psychiatry Rotation, at the County Courthouse to swear an affidavit for a three-party petition for a patient who was very ill and decompensating. After that I was to drive to the airport and pick up Dr. Alan F. Schatzberg, and escort him around in advance of giving the MCW Grand Rounds the next day. The trip to the courthouse was innocuous enough, I, and the other two of our three person party all made our statements and signed the notarized copies. However there was already an air of surrealism about. There were rumors that airplanes had been hijacked from US airports. As we left the courthouse, there were deputies taking posts at all the buildings and parking lot entrances. When I got to the Downtown CSPs office, next to the Federal Building in downtown Milwaukee, the reports and news footage was starting showing the planes crashing into the World Trade Center Twin-Towers. Clinic leadership had a discussion about staying open versus closing given the close proximity of the office to the Federal Building. After all flights in the US were grounded I was notified that Dr. Schatzberg was stuck in Boston and would be rescheduled for another time. About then the reports of the plan crashing in the field in Pennsylvania were coming in, quickly followed by reports of a plane crashing near or into the Pentagon in Washington. I knew that a good friend of mine from my Army years was assigned to the Pentagon and wondered if he was alright. I got in my car and drove in a somewhat numb state of shock back to the Tosa Clinic and then headed home to check on my wife and children.

America’s innocence was lost… None-the-less, trauma’s both natural and man-made have been around for quite a while, but our understanding of it has lagged behind until Psychiatry has pushed the boundaries of the medical knowledge of mental illness. Unfortunately, with the growing complexities of the post-modern world and the proliferation of traumatic incidents, our appreciation of grief and responses to trauma has grown too. So much so that the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th Edition, has added a specific chapter for disorders whose symptoms are preceded by a traumatic or distressing event. In addition, they have shifted the conceptual focus from a predominantly anxiety reaction based focus to a more nuanced research and neurobiological based paradigm that have criteria that reflect the real world variability of responses. To appreciate the growing scope of the problem of trauma we need to look no farther that the news headlines in just 2013. We can note the Boston Marathon Bombing, the Syrian Civil War including the alleged use of chemical weapons, the continuing combat operations in Afghanistan, ongoing North Korean Missile Threats, over 100 shootings involving more than 4 victims in the US as a whole including the civilian contractor whom went on a shooting rampage at a Naval office in DC Naval Yard killing 12, many natural disasters including the Typhoon Haiyan hitting the Philippines and the Moore, Oklahoma tornado killing 23 and injuring almost 400. It is in this context that the Wisconsin Psychiatric Association has decided to theme our 2014 Annual Meeting on “PTSD and Trauma: An update on everything that you’re afraid of! Epidemiology, Nosology, Evaluation, and Treatment.” We have a great schedule of presentations planned including Dr Rachel Yehuda, Professor of Psychiatry at the Mount Sinai School of Medicine, and Director of their Traumatic Stress Studies

WisconsinThe

PsychiatristQUARTERLY PUBLICATION OF THE WISCONSIN PSYCHIATRIC ASSOCIATION: NORTHERN, SOUTHERN AND MILWAUKEE CHAPTERS

Winter

2014Vol. 54 No. 4

Trauma: A growing concern with often dire results Attend the WPA Annual Conference on Trauma/PTSD, March 6-8, 2014By John Schneider, MDChairman, WPA Annual Conference Committee

Continued on page 2

The Wisconsin Psychiatrist

2

Division presenting on Intergenerational Transmission of Trauma and Biomarkers of PTSD. Drs. Eileen P. Ahearn and Rachel C. Molander of the Madison Veterans’ Administration will present on Medical and Psychiatric Comorbidities and Evidence Based Psychopharmacologic Treatments. In addition we will hear from Milwaukee Area Psychologists Drs. John Prestby and Cynthia Valentin on Trauma Informed Care Evaluation Strategies and Psychotherapeutic Treatments. In addition we will broaden our view with presentations by Dr. Jon E Gudeman on A Historical Perspective of Trauma, myself on Trauma and the Medical System, Dr Mike McBride will give us a view into Trauma, Psychiatry and the US Military and Drs.

Jon Berlin and Jeff Taxman will present on Trauma in emergency settings and disasters. To round out our experience with residents will present cases for discussion and consolation with our experts. We will be making a return to the American Club in Kohler for our meeting. It is an elegant, adult, yet comfortable and intimate setting so that we can also come together as friends, peers and colleagues in hopes that our own humanity can carry each of use forward with the challenging work we do every day in our practices. On behalf of WPA President Dr. Halverson, the WPA Executive Council, and the Annual Meeting Committee, I greatly encourage you to attend.

On Thursday, March 6, on the eve of the Wisconsin Psychiatric Association Annual Meeting in Kohler with the theme of PTSD, the WPA and the Wisconsin Academy of Child and Adolescent Psychiatrists will be holding a combined dinner meeting featuring expert in Child and Adolescent PTSD Ryan Herringa, M.D./ Ph.D. from the University of

Wisconsin School of Medicine and Public Health. Dr. Herringa will present “Pediatric PTSD: From Impact to Treatment” and will participate in a facilitated discussion on this topic as well as other important topics in psychiatry across the life span.

Dr. Herringa is an Assistant Professor of Child & Adolescent Psychiatry at the University of Wisconsin School of Medicine and Public Health. He completed his MD/PhD at the University of Wisconsin, his adult and child psychiatry residency at the University of Pittsburgh, and then returned to the UW as faculty.

During residency he learned the use of trauma-focused CBT to treat pediatric PTSD under the direction of Drs. Judith Cohen and Anthony Mannarino. His research explores the brain biology

of pediatric trauma and post-traumatic stress disorder using functional MRI. This research is beginning to yield important insights into how regulation of the brain’s fear circuits may be impaired in pediatric PTSD. He has received support to conduct this research through the AACAP Pilot Research and Junior Investigator Awards, the NARSAD Young Investigator Grant, and a pending NIMH Career Development Award. He has also received support through the UW Institute for Clinical and Translation Research to begin coordinating his MRI studies with school-based screening and treatment of traumatized youth, with the goal of examining whether successful treatment can restore resilience to the brain’s fear regulatory circuits.

Two CME credits will be offered for this dinner presentation and discussion. A separate registration option is available for the Thursday dinner program; WPA Conference attendees are encouraged to sign up for this program in addition to the full conference.

Please consider joining your psychiatric colleagues from across the lifespan for a chance to network and learn about more of the cutting edge research and treatment going on regarding pediatric PTSD in our own state.

Combined WPA/WIAACAP Dinner Meeting in Kohler to Feature PTSD in Children and AdolescentsBy Jerry L. Halverson, MDPresident, Wisconsin Psychiatric Association

Continued from page 1

Continued on page 3

Attention Resident-Fellow Members!

The 2nd Annual Clinical Case Vignette Competition will be held during the WPA Annual Conference March 6-8 at the American Club in Kohler. The event provides a fun, educational and rewarding opportunity for residents. Interested? Submit your clinical

vignette abstract to WPA@badgerbay.co by February 3rd. Two residents will be selected from each program to present on March 8th at the Conference. Contact your residency program or the WPA office for more information.

The Wisconsin Psychiatrist

3

President’s Page on ParityBy Jerry L. Halverson, MDPresident, Wisconsin Psychiatric Association

Welcome back to the President’s Page. This is the third edition of our ongoing discussion of the issues of the day in Wisconsin Psychiatry. It has been a pretty busy few months for your WPA leadership with the passage of the Speaker’s Taskforce bills through the Assembly, action in the courts, as well as the release of the long awaited federal

parity regulations. You will read elsewhere in the newsletter about the Speaker’s Taskforce bills as well as the unique legal issues that your WPA leadership engaged in over the past few months. Given this, I decided that I would use this space to disseminate information on the federal parity regulations, as we have waited for them for five years and they will have an immediate impact on the care that we provide.

Prior to the release of the regulations, the federal parity law and what it meant was up for debate. Usually it went like this: Clinician feels it means one thing in service of the patient, and the insurance company disagrees. The insurance company generally “won” this debate as there is a great deal of gray area in the parity law. This created a frustrating situation for patients and providers alike. I have added talking points from the Parity Implementation Coalition, a group that APA is involved with, to help clarify the meaning of the regulations.

The Departments of Treasury, Labor and Health and Human Services issued a long awaited final rule on Friday November 8, 2013 governing the implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA).

A. Scope of Service The final rule clarified the scope of service issue by stating: 1. The 6 classification of benefits scheme (inpatient in and

out-of-network, outpatient in and out-of-network, emergency care, and prescription drugs) was never intended to exclude intermediate levels of care (intensive outpatient, partial hospitalization, residential).

2. The language in the final rule on scope makes it clear that each classification and sub-classification has to meet all parity tests within each classification. The rule further states that “the classifications and sub-classifications are intended to be comprehensive and cover the complete range of medical/surgical benefits and mental health or substance use disorder benefits offered by health plans and issuers.” This language, coupled with the new specific examples around intermediate levels of care, makes it clear that MH/SUD services have to be comparable to the range and types of treatments for medical/surgical treatment within each class.

3. Although neither the Interim Final Rule (IFR), nor final rule mandate, specifies services required to be offered by plans under the 6 classification scheme, the final rule clarifies that plans must assign intermediate services in the behavioral health area to the same classification as plans or issuers assigned intermediate levels of services for medical/surgical conditions. The net effect of this provision is that parity requirements (as clarified by the FAQs issued by the Department of Labor) extend to intermediate levels of MH/

SUD care and that such services must be treated comparably under the plan.

B. Non-Quantitative Treatment Limitations (NQTLs) • The final rule strikes the provision included in the IFR that

permitted plans to apply discriminatory limits on mental health/substance use disorder (MH/SUD) treatment if there was a “clinically recognized standard of care that permitted a difference.”

• Under the final rule, parity requirements for NQTLs are expanded to include restrictions on geographic location, facility type, provider specialty and other criteria that limit the scope or duration of benefits for services (including access to intermediate levels of care). The net effect of this is that plans will no longer be able to require a patient to go to an MH/SUD facility in their own state if the plan allows plan members to go out of state for other medical services.

• The final rule does not include a new quantitative floor or formula on how plans may apply NQTLs to MH/SUD.

• The final rule maintains the “comparable and no more stringently” standard on NQTLs without defining the term and continues to require plans to disclose the “processes, strategies, evidentiary standards and other factors used by the plan or issuer to determine whether and to what extent a benefit is subject to an NQTL be comparable and applied no more stringently for MH/SUD than for medical/surgical.”

• The improvement in the final rule is that plan participants or those acting on their behalf will now be able to request a copy of all relevant documents used by the health plan to determine whether a claim is paid (see disclosure section for more detail on what documents may be requested. Current or potential enrollees may request this information and plans are required to provide it within 30 days).

• The final rule confirms that provider reimbursement rates are a form of NQTL. The preamble clarifies that plans and issuers can look at an array of factors in determining provider payment rates such as service type, geographic market, demand for services, supply of providers, provider practice size, Medicare rates, training, experience and licensure of providers. The final rule reconfirms that these factors must be applied comparably and no more stringently to MH/SUD providers. Additional comments will be solicited if questions persist with respect to provider reimbursement rates.

C. Disclosure and Transparency MHPAEA requires that the criteria for medical necessity determinations be made available to any current or potential enrollee or contracting provider upon request. MHPAEA also requires that the reason for the denial of coverage or reimbursement must be made available upon request. New disclosure requirements in the final rule will require plans to provide written documentation within 30 days of how their processes, strategies, evidentiary standards and other factors used to apply an NQTL were imposed on both medical/surgical and MH/SUD benefits.

If you have further questions regarding the final parity rule or would like to report a violation, please visit www.psych.org/parity.

Winter 2014

4

On October 29th, the WPA Milwaukee Chapter held a spirited, well-attended, two-hour meeting in Wauwatosa with Milwaukee County Executive, Chris Abele, and his Director of Health and Human Services, Héctor Colón. WPA members came from all over the area’s private, public and academic sectors.

Mr. Abele described two of his administration’s highest priorities: fiscal responsibility and protection of the county’s most vulnerable individuals. Regarding mental health in Milwaukee, he expressed urgency about changing the model of care to one that increases the community capacity, and he stated his commitment generally to a provision of better care. Mr. Abele said he was not an expert and welcomed “good, honest feedback.”

Mr. Colón expanded on the theme of increasing treatment resources in the community and reducing the need for hospital and emergency care. Due to current and past efforts, he said, the Behavioral Health Division (BHD) has recently realized 19% fewer emergency detentions, 13% less visits to the Psychiatric Crisis Service (PCS), and 40% less utilization of the acute inpatient service.

He described 15-20 different initiatives currently planned or underway, such as making the Adult Mobile Team a 24/7 service and accessing new Community Recovery Service 1915i Medicaid monies. He also referenced the plan to downsize another 12 acute adult beds at the Mental Health Complex, contracting out uninsured patients to private hospitals, completely closing the long-term care units by 2015 and ultimately decentralizing BHD and moving it away from the medical center.

Mr. Colón, who has experience administering a Community Support Program, said the County was committed to maintaining a safety net service, which he called “a statutory and moral obligation.” He said BHD would provide this service “for as long as necessary”, but wondered if it could one day be contracted out. He expressed interest in relocating PCS to Froedtert’s emergency department.

Audience responses and inquiries reflected a wealth of professional experience, and were well received by the County representatives as a true information exchange. Some of the concerns raised, primarily as they relate to the County’s plans for BHD are outlined below:

• The lack of clinical and administrative leadership within a major Milwaukee County healthcare system—which has been operating for months with no medical director and only an acting director—means the absence of care coordination between the County and the agencies and hospitals it relates to.

• Further downsizing beds risks a return to earlier systemic problems of hospital crowding or backups in the emergency medical system;

• Psychiatric hospitalization is needed for patients with clinical characteristics that private hospitals will not accept.

• BHD’s current model for delivering emergency and inpatient psychiatric care through PCS is considered by some experts as a model of state-of-the-art emergency psychiatric care.

• Chapter 51 unnecessarily routes all cases to County—with

WPA Milwaukee Chapter members engage in candid conversation with Milwaukee County Executive and Director of Health & Human ServicesBy Jon Berlin, MD

Continued on page 5

Wisconsin Psychiatric Association2014 Annual MeetingMarch 6-8, 2014The American Club, Kohler, WIPTSD and Trauma: An update on everything that you’re afraid of! Epidemiology, Nosology, Evaluation, and Treatment

Join WPA as we welcome national and local experts to discuss: • PTSD and Trauma Informed Care: Evaluation Strategies,

Biologic and Psychotherapeutic Treatments • Trauma, Society and the Post Modern World • Trauma, Psychiatry and the US Military • Trauma, Psychiatry and Disasters

Register today at www.thewpa.orgLodging Information Call The American Club at 800-344-2838 and select OPTION #6 to reserve your room today! Indicate you are booking as part of group block RESERVATION # 81Y6E1 for the Wisconsin Psychiatric Association. Room Rates: Thursday, March 6 and Friday, March 7, 2014 - $159 single/$189 double. Reservation deadline: February 4, 2014.

The Centers for Medicare and Medicaid Services (CMS) issued its Final Rule for the 2014 Medicare Physician Fee Schedule (PFS) on Wednesday, November 27. The Final Rule appeared in the December 10, 2013 publication of the Federal Register. Most provisions of the Final Rule are ef-fective January 1, 2014. Comments on a few specific issues will be accepted through January 27, 2014. To read APA’s five-page summary, go to www.thewpa.org.

American Psychiatric Association Summary Final Rule for the 2014 Medicare Physician Fee Schedule

The Wisconsin Psychiatrist

5

Psychiatrists and residents from across the country descended upon Capitol Hill for the APA’s National Advocacy Day in November. Think advocacy bootcamp for those of us less educated in the ways of political savvy than clinical practice. This year, I had the pleasure of joining our very own DC regulars, Clarence Chou and Jerry Halverson, who, fortunately, knew their way through the maze of security entrances and underground tunnels that make up the various legislative office buildings.

Following a full day of presentations on legislative issues relative to psychiatry and pep talks by APA staffers and political analyst Chuck Begala and Senator Kelly Ayotte, we were sent out to visit the offices of our state representatives and senators. I am pleased to report that Wisconsin covered eight separate offices, including both senators, which was more than just about any other group represented.

Topics discussed with the healthcare legislative aides included:

“Comprehensive Mental Health Legislation”• Support passage of S.689 and introduction of companion

legislation in the House which supports the Mental Health Awareness and Improvement Act.

“Mental Health Services and Veterans”• VA Office of Inspector General: “VHA’s greatest challenge

has been to hire and retain psychiatrists”• APA proposes “Ensuring Veterans Resiliency Act”• Raise loan forgiveness for VH positions to the rate for current

Department of Defense positions

• Support of the newly launched BRAIN initiative• Support for monitoring and implementing the VHA’s training

for diagnosing and treating military sexual trauma across all VA and DoD facilities

• Support for continued growth of tele-mental health and mobile vet centers.

“Congress Should Not Define Psychologists to be “Physicians” Under Medicare”• APA opposes H.R. 794 and S. 1064 which seeks to define

psychologists as “physicians” under Medicare

“Enhancing Psychiatric Services Access in Medicaid”• APA H.R. 1838 and S.755 which would add psychiatrists,

neurologists, and OB/GYNs to an ACA provision that increases Medicaid reimbursement rates for certain primary care services to Medicare levels.

“Federal Public Health and Research Funding”• Seeking to protect healthcare research funding when

searching for budget cuts as part of sequestration• Writer was surprised by the amount of support for such

research by our most “financially conservative” folk in Congress and the Senate.

“Improving Psychiatric Care in Native American Country”• APA supports H.R. 2037 Native American Psychiatric and

Mental Health Care Improvement Act• Grants for psychiatry departments at medical schools or

affiliated nonprofit organizations to bring psychiatric services to underserved American Indian or Alaska Native communities.

After meeting with many legislative aides, I was impressed by how well most knew the given healthcare landscape and realized how important it is to reach these particular people as they are the closest advisors to the representatives and senators who actively vote on the various bills. I can see how important it is to form personal relationships with the members of these offices and was again impressed with how well Clarence Chou has come to know the staff of so many offices over the years.

Biggest takes-homes:

• Develop relationships with the staff of legislative offices. It is

It doesn’t matter how good your idea may be. Without advocacy, it will forever be just that… an ideaAmerican Psychiatric Association National Advocacy Day(s) – November 6-8, 2013By Jake Behrens, MD

Drs. Jake Behrens and Clarence Chou on Capitol Hill

Congratulations to the Medical College of Wisconsin for making the APA’s 100% Club, and a “thank you” to Dr. Rajni Aulakh, MCW

Resident Representative to the WPA’s Executive Council, for her extra work in coordinating this effort.

MCW 100% Club Recognition

Continued on page 6

proper emergency detention authority provided to ER docs and community psychiatrists, individuals in crisis needing involuntary acute care could bypass PCS and go directly into a private hospital.

After lengthy discussion on these and other topics that provided attendees with the opportunity for an open and respectful exchange of ideas, Mr. Colón and Mr. Abele were warmly thanked for sharing so generously of their time.

Continued from page 4

Winter 2014

6

Sticking with the time-honored traditional theme of “year-end” articles… As 2013 comes to a close, we look back on a busy and very good year for WPA’s legislative and policy efforts:

February 6 – Saying, “Issues surrounding mental illness affect families across Wisconsin. Unfortunately, we don’t talk about the issues that we all know exist, and we don’t do enough to address them,” Assembly Speaker Robin Vos (R-Rochester) announces the creation of a Speaker’s Task Force on Mental Health. The bipar-tisan Task Force is charged with taking public input and making recommendations for eliminating barriers to early mental health care for children and adults.

February 27 – Co-Chaired by Rep. Erik Severson, MD (R-Oceola) and Rep. Sandy Pasch (D-Shorewood), the Speaker’s Task Force meets for the first time. Jerry Halverson, MD (then WPA President-Elect) sets the tone as the initial physician or mental-healthcare provider to present testimony.

March 27 – Stephanie Eken, MD testifies on behalf of WPA before the Task Force about the specific needs of child and adolescent mental health patients.

April 5 – Rep. Jim Ott (R-Mequon) introduces Assembly Bill 139 – the so-called “Jandre Bill” to address the Wisconsin Supreme Court’s 2012 decision effectively requiring physicians to inform patients of all possible diagnoses (including those ruled-out by the physician), all possible diagnostic tests and all possible treatment protocols. Sen. Glenn Grothman (R-West Bend) introduces an identical Senate companion bill.

• September 12 – WPA members attend WPA’s 2013 Legislative Day in Madison. Coordinated with the Task Force’s consider-ation of recommendations, WPA members meet with lawmak-ers to advocate for four key proposals:

• Psychiatry & Primary Care Access Grant Program – designed to provide grant money to physicians practicing psychiatry or primary care in underserved areas.

• Child Psychiatry Access Line – designed to provide access to specialty psychiatric care for primary care physicians treating

patients in areas without immediate access to psychiatrists.

• Mental Health Care Coordination – also called “HIPAA

• Harmonization,” MHCC is designed to allow physicians greater coordination and improved care across specialties for patients with mental health conditions.

• The Jandre Bill – designed to reset the notion of physician-informed consent to a reasonable standard, ensuring patients are appropriately informed but not overwhelmed with unneces-sary information in making care and treatment decisions with their physicians.

October 10 – The Senate Judiciary Committee amends (with support of the physician community) and then votes in favor of pas-sage of the Jandre bill (AB 139).

October 15 – The full Senate votes unanimously in support of the now-amended AB 139.

October 22 – WPA testifies before the Assembly Health Commit-tee in favor of The Child Psychiatry Access Line (AB 452), Mental Health Care Coordination (AB 453) and Psychiatry & Primary Care Access Grant Program (AB 454).

November 5 – The Assembly Health Committee votes to recom-mend passage of AB 452, AB 453 and AB 454. Meanwhile, the full Assembly votes in favor of the amended-AB 139 sending the Jandre bill to the Governor.

November 12 – The full Assembly votes to pass AB 452, AB 453, AB 454. (All now await consideration by the full Senate which will return in January 2014.)

December 11 – Governor Walker signs Assembly Bill 139 (the “Jandre Bill”) into law bringing the concept of informed consent back into line with longstanding physician and patient practice.

As the year ends, we are actively engaged in planning Doctor Day in Madison (February 12, 2014). A first-ever cross-specialty legislative day jointly sponsored and jointly planned by many dif-ferent groups, Doctor Day is designed to bring physicians together

Continued on page 7

WPA – Ending 2013 StrongBy Eric Jensen, Jensen Government Relations; WPA Legislative Counsel

much better to have a relationship and understanding before needing to ask for something.

• Discussions of experiences across the state as various staff are often from throughout Wisconsin. Clarence discovered he knew the family of Rep. Duffy’s new healthcare legislative aide which led to said aide requesting a picture with Dr. Chou.

• Send personal follow-up emails to the people you’ve met. As the result of a personal follow-up, I was able to attend the birthday celebration of a well-informed healthcare aide in Ron Kind’s office when back in DC for the AMA Interim Meeting.

I have to say that I learned more about how things work on the Hill in one night out on H Street than in any formal presentation. It was much more enjoyable returning to the same offices having recently met members of the various offices.

• It doesn’t matter what we think should be… without being able to effectively relay our message, very little will change. For this, we are truly grateful for the sacrifices and dedication of our advocacy staff and for the years spent doing just this by our members (Clarence and Jerry, you’ve once again impressed this WPA member.)

Continued from page 5

The Wisconsin Psychiatrist

7

WPA is pleased to announce the following members were recently elected to the status of Fellow of the American Psychiatric Association:

They will be honored at the 2014 Convocation of Distinguished Fellows ceremony, during APA’s Annual Meeting in New York on Mon-day, May 5, at 5:30 p.m. at the Jacob J. Javits Convention Center.

The Wisconsin Psychiatric Association is proud to have among its membership a number of individuals who have been recognized as Distinguished Fellows of the American Psychiatric Association. Achieving this status marks a significant career milestone, and honors the continued membership and achievements of these members at both the state and national levels.WPA leadership is working with APA to identify members who will be eligible to apply

for Distinguished Fellowship status in 2014. APA qualifications in-clude the individual has been a general member and/or fellow for eight years or more, has board certification, has made significant contributions through active involvement, and is nominated by their District Branch. WPA will invite eligible members to partici-pate in the formal application process in early spring.

American Psychiatric Association to Recognize the Newest Fellows

Distinguished Fellowship Notification

Alexander Fritz, DOAndrea H Levy MDAngela C Janis, MDAnne Marie Miller, MD

Claudia L Reardon, MDCynthia M Stanford, MDNancy Jane Wilson, MDRobert J Vickrey, MD

EDITORIAL BOARD CORNER By Frederick Langheim, MD, PhD

This issue marks the eighth installment from the Editorial Board con-solidating recent clinical updates, mental health policy news, popular press news patient’s may be reading, and changes in the landscape of psychiatry in Wisconsin. If you find you have announcements you would like included in a future issue please email: WPA@badgerbay.co.

OF GENERAL INTEREST:English Majors for Empathy:A recent study in Science (Kidd and Castano) correlated improved theory of mind with exposure to literary fiction, conducting experiments which demonstrated improved cognitive and affective theory of mind testing following exposure to literature.

Spurious Results Continued:An article appearing in The Economist (10/19/2013) titled “How science goes wrong” continues the exploration of false positives and misrep-resentation in the scientific literature, stating “A rule of thumb among biotechnology venture-capitalists is that half of published research cannot be replicated. Even that may be optimistic. Last year researchers at one biotech firm, Amgen, found they could reproduce just six of 53 “landmark” studies in cancer research. Earlier, a group at Bayer, a drug company, managed to repeat just a quarter of 67 similarly important papers. A leading computer scientist frets that three-quarters of papers in his subfield are bunk. In 2000-10 roughly 80,000 patients took part in clinical trials based on research that was later retracted because of mistakes or improprieties.”

CLINICAL PSYCHIATRY IN THE NEWS, IN BRIEF:Harsh Superego Located?The right lateral prefrontal cortex appears to be correlated with adher-ence to social norms. In a study published in Science, Ruff, Ugazio and Fehr reported: “We show that the right lateral prefrontal cortex (rLPFC) is involved in both voluntary and sanction-induced norm compliance. Both types of compliance could be changed by varying the neural excit-ability of this brain region with transcranial direct current stimulation, but they were affected in opposite ways, suggesting that the stimulated region plays a fundamentally different role in voluntary and sanction-based compliance. Brain stimulation had a particularly strong effect on compliance in the context of socially constituted sanctions, whereas it left beliefs about what the norm prescribes and about subjectively expected sanctions unaffected.”

Autism Rates Plateau In UK:According to a study by Taylor, Jick and MacLaughlin (BMJ, 2013) au-tism rates increased fivefold during the 1990s and plateaued in the early 2000s, remaining steady through 2010.

Spanking, Externalizing and Language:In a longitudinal study of nearly 2000 families, MacKenzie et al (Pedi-atrics, 2013) demonstrated that even minimal spanking by mothers at ages 3 to 5 years was associated with greater externalizing behaviors and lower receptive vocabulary scores at age 9.

Continued from page 6

Continued on page 8

in the Capitol in larger numbers than ever before. The time is long overdue for physicians to truly show themselves in our political pro-cess – alone we simply cannot speak loudly enough, but united as physicians and across specialties and organizations that have often

divided us, we can be a strong voice for physicians and patients. Put an exclamation point on WPA’s 2013 by signing up for Doctor Day (go to www.theWPA.org) – you need to be there!!

Winter 2014

8

Continued on page 9

Irregular Bedtime = Behavior Problem:In a study of over 10,000 7-year olds, excluding ADHD and Autism Spectrum disorders, irregular bedtimes were correlated with greater behavioral difficulties in both parent and teacher reports (Kelly, Beng, and Sacker, Pediatrics, 2013).

Blood Sugar and Cognition:According to Kerti et al. (Neurology, 2013) higher glucose correlates with lower memory and reduced hippocampal microstructure. “Lower HbA1c and glucose levels were significantly associated with better scores in delayed recall, learning ability, and memory consolidation. In multiple regression models, HbA1c remained strongly associated with memory performance. Moreover, mediation analyses indicated that beneficial effects of lower HbA1c on memory are in part mediated by hippocampal volume

Moreover, mediation analyses indicated that beneficial effects of lower HbA1c on memory are in part mediated by hippocampal volume and microstructure.” They concluded “Our results indicate that even in the absence of manifest type 2 diabetes mellitus or impaired glucose tolerance, chronically higher blood glucose levels exert a negative influence on cognition, possibly mediated by structural changes in learning-relevant brain areas. Therefore, strategies aimed at lowering glucose levels even in the normal range may beneficially influence cognition in the older population, a hypothesis to be examined in future interventional trials.”

Depression Accelerates Aging?According to research published in Molecular Psychiatry (Verhoeven et al., 2013), major depression is associated with cellular markers of aging. The researchers measured telomere length as a proxy for cellu-lar age. Telomeres are the cap (like an aglet on your shoe laces) which preserves the ends of chromosomal DNA and slowly shortens with age. The researchers found “that depressed patients show acceler-ated cellular aging according to a ‘dose–response’ gradient: those with the most severe and chronic MDD showed the shortest TL [telomere length]. We also confirmed the imprint of past exposure to depression, as those with remitted MDD had shorter TL than controls.”

Polypharmacy Prevalent in Autism Spectrum:According to Spencer et al (Pediatrics, 2013) psychotropic poly-pharmacy is common in autism spectrum disorders despite limited evidence of benefit. According to the abstract: “Among 33 565 children with ASD, 64% had a filled prescription for at least 1 psychotropic medication, 35% had evidence of psychotropic polypharmacy (≥2 classes), and 15% used medications from ≥3 classes concurrently. Among children with polypharmacy, the median length of polyphar-macy was 346 days. Older children, those who had a psychiatrist visit, and those with evidence of co-occurring conditions (seizures, attention-deficit disorders, anxiety, bipolar disorder, or depression) had higher odds of psychotropic use and/or polypharmacy.” The authors conclude: “Despite minimal evidence of the effectiveness or appropri-ateness of multidrug treatment of ASD, psychotropic medications are commonly used, singly and in combination, for ASD and its co-occur-ring conditions. Our results indicate the need to develop standards of care around the prescription of psychotropic medications to children with ASD.”

Cannabis, Cocaine and Impulse Control:A Dutch study appearing in the British Journal of Pharmacology (van Wel et al.) reported: “Results showed that single doses of cannabis impaired psychomotor function and increased response errors during impulsivity tasks. Single doses of cocaine improved psychomotor function and decreased response time in impulsivity tasks at a cost of making more errors.”

Vitamin D and First Break?A study of 69 patients with first episode psychosis and 69 matched case controls found significantly lower levels of Vitamin D (Crews et al., Schizophrenia Research) in those with first episode psychosis.

Exercise as Antidepressant:In a recent review appearing in the American Journal of Preventive Medicine, Mammen and Faulkner (2013) sought to determine the impact of exercise on future episodes of depression. They wrote: “The initial search yielded a total of 6363 citations. After a thorough selec-tion process, 30 studies were included for analyses. Among these, 25 studies demonstrated that baseline physical activity (PA) was nega-tively associated with a risk of subsequent depression. The majority of these studies were of high methodologic quality, providing consistent evidence that PA may prevent future depression. There is promising evidence that any level of PA, including low levels (e.g., walking <150 minutes/weeks), can prevent future depression.”

Better Hospital Lights Indicated:The Journal of Advanced Nursing ran an article (Bernhofer et al., 2013) suggesting that poor hospital lighting may impact patient outcomes by impairing normal circadian rhythm, quality of sleep and lowering affect. The study abstract reported: “Light exposure levels were low: mean daytime light intensity was 104·80 lux. Sleep time was fragmented and low: mean 236·35 minutes of sleep/night. Intra-daily stability scores indicated little sleep–wake synchronization with light. Fatigue and total mood disturbance scores were high and inversely associated with light. Pain levels were also high and positively as-sociated with fatigue, but not directly with light exposure. Low light exposure significantly predicted fatigue and total mood disturbance. Medical inpatients were exposed to light levels insufficient for circadian entrainment. Nevertheless, higher light exposure was associated with less fatigue and lower total mood disturbance in participants with pain, suggesting the need for further investigation to determine if manipulat-ing light exposure for medical inpatients would be beneficial in affect-ing sleep–wake disturbances, mood and pain.”

Poverty = Smaller Brains?An article appearing in JAMA Pediatrics (Luby et al., 2013) investi-gated the impact of poverty on brain development. The authors found that “Poverty was associated with smaller white and cortical gray mat-ter and hippocampal and amygdala volumes. The effects of poverty on hippocampal volume were mediated by caregiving support/hostility on the left and right, as well as stressful life events on the left.” Mind Wandering = Less Pain Perception?AMA Morning Rounds newsletter reported: “The NPR (10/29, Shute, 465K) “Shots” blog reported that, according to a study conducted by researchers at the University of Toronto’s Centre for the Study of Pain, “people who were good at letting their minds wander away from pain had more nerve connections to a brain region that produces painkill-ing substances.” Researchers arrived at that study after conducting magnetic resonance imaging scans on 32 individuals. The investiga-tors also discovered that “the brain made that connection using a system called the default-mode network, which people typically use for thinking.””

Top Selling Drugs:Medscape ran an article on the top 100 drugs by sales from 10/1/2012 to 9/30/2013. Among them were: Abilify, ranked number 1 with $6,391,050,009 in sales, Cymbalta, ranked 3rd, with $5,432,152,672 in sales, Oxycontin, ranked 12th with sales of $2,637,737,756,

Continued from page 7

The Wisconsin Psychiatrist

9

Continued from page 8

Continued on page 10

Vyvanse at $1,709,395,031 ranked 28th, and Suboxone, ranked 30th, at $1,554,971,998. Additional psychotropics on the list included Seroquel XR at 36 with $1,219,959,533 in sales, Lunesta at 64 with $822,435,175, Invega Sustena at 75 with $733,468,004, Focalin XR at $673,003,743, Pristiq at 92 with $625,502,793, and Strattera at $613,531,907.

Vyvanse for Binge Eating?On 11/5 Bloomberg News reported (Kelly) that Shire had completed a final stage of clinical testing of Vyvanse in treatment of binge-eating, demonstrating a reduction in episodes over twelve weeks of treat-ment with the drug, compared to placebo, in a group of 773 patients.

$2.2 Billion False Claims for Risperidone:The AMA Morning report (11/6/13) documented: “Major newspapers, wire sources, and business journals report that Johnson & Johnson will pay more than $2.2 billion to settle US civil and criminal cases alleging false marketing practices for the antipsychotics Risperdal (risperidone) and Invega (paliperidone), as well as for the heart medicine Natrecor (nesiritide), in what is third largest healthcare fraud settlement the US has seen to date. The civil settlement will resolve lawsuits filed under the False Claims Act.”

More Sleep = Less Calories:In a counterbalanced, crossover design study of 37 children ages 8 to 11, Hart et al (Pediatrics, 2013) found that, as opposed to the low sleep condition (confirmed by actigraphy) “increased sleep duration in school-age children resulted in lower reported food intake, lower fasting leptin levels, and lower weight.”

Gabapentin for Alcoholism:In a 12-week double-blind placebo-controlled dose-ranging study of 150 men and women over 18 years of age with alcohol dependence (Mason et al., JAMA Internal Medicine, 2013), gabapentin improved the rates of abstinence and no heavy drinking. “Gabapentin (particu-larly the 1800-mg dosage) was effective in treating alcohol depen-dence and relapse-related symptoms of insomnia, dysphoria, and craving, with a favorable safety profile.”

Eyes May Reveal Autism at 2-6 Months:In a research letter appearing in Nature online 11/6/2013, and widely publicized in the popular press, Jones and Klin found that “Atten-tion to eyes is present but in decline in 2-6 month-old infants later diagnosed with autism” (a rather self explanatory article title). They found that eye fixation “is not immediately diminished in infants later diagnosed with ASD; instead, eye looking appears to begin at norma-tive levels prior to decline. The timing of decline highlights a narrow developmental window and reveals the early derailment of processes that would otherwise have a key role in canalizing typical social development.”

Bilingualism Delays Dementia?In a review of 648 cases of dementia (391 of the patients being bilingual) Alladi et al. (Neurology, 2013) found that bilingual patients developed dementia 4.5 years later than monolingual patients, with significant age of onset differences across Alzheimer disease demen-tia, frontotemporal dementia and vascular dementia. They found no additional benefit to speaking more than two languages.

Exercise in Pregnancy = Faster Brain Development?In research presented at this year’s Society for Neuroscience confer-ence, professor Dave Ellemberg, from the University of Montreal, and graduate student Élise Labonté-LeMoyne, reported on their findings that expectant mothers who exercised at least 20 minutes a day 3

days a week had children who at ages 8 and and 12 days had evi-dence of greater brain maturity than those children born to mothers who did not exercise, as measured by EEG markers of repeated and novel sounds. This was reported in Medical News Today by Marie Ellis, as appeared on-line 11/11/2013. Military Suicides Down 22%: According to the AMA Morning report: “The AP (11/12, Baldor) reports that, according to officials from the Department of Defense, US military suicides across all branches of the service “have dropped by more than 22 percent this year.” The drop has occurred “amid an array of new programs targeting what the Defense Department calls an epidemic that took more service mem-bers’ lives last year than the war in Afghanistan did during that same period.” Nevertheless, officials with the military expressed reluctance “to pin the decline on the broad swath of detection and prevention efforts, acknowledging that they still don’t fully understand why troops take their own lives,” particularly since some suicides occur in service members who have never been deployed to battle.”

PTSD and Obesity:A study appearing in JAMA Psychiatry (on line ahead of print Kuban-sky et al.) found a strong correlation between PTSD symptoms and obesity. That is, women with at least 4 PTSD related symptoms had a faster rise in BMI compared to those without them, while having had similar BMI trajectories prior to onset of PTSD symptoms.

FDA, Richter and Schizophrenia:According to the AMA newsletter of 11/22/2013: “The AP (11/21) re-ports Forest Laboratories Inc. said the FDA is seeking more informa-tion on its “potential schizophrenia treatment cariprazine before” it de-cides whether to approve the drug. The FDA “indicated that additional clinical trial data” would be required. Forest said “it believes this re-quest was made to better define the best dosing regimen to maintain the drug’s effectiveness while minimizing side effects.” Forest and Hungarian firm Gedeon Richter PLC are partnering on the drug and plan to confer with FDA officials over future action. Richter developed cariprazine but licensed it to Forest in the US and Canada.”

Psychobiotics?In an article in Biological Psychiatry (74(10):720-726), Dinan, Stanton and Cryan wrote: “So far, psychobiotics have been most extensively studied in a liaison psychiatric setting in patients with irritable bowel syndrome, where positive benefits have been reported for a number of organisms including Bifidobacterium infantis. Evidence is emerg-ing of benefits in alleviating symptoms of depression and in chronic fatigue syndrome. Such benefits may be related to the anti-inflam-matory actions of certain psychobiotics and a capacity to reduce hypothalamic-pituitary-adrenal axis activity. Results from large scale placebo-controlled studies are awaited.”

Recession and Cognitive Function:According to a BMJ article by Leist Hessel and Avendano, expe-riencing a recession in adulthood may have negative impacts on cognition. According to their results: “Among men, each additional recession at ages 45–49 was associated with worse cognitive func-tion at ages 50–74 (b=−0.06, CI −0.11 to −0.01). Among women, each additional recession at ages 25–44 was associated with worse cognitive function at ages 50–74 (b25–34=−0.03, CI −0.04 to −0.01; b35–44=−0.02, CI −0.04 to −0.00).”

Astrocytes Raised Up?In a journal Nature paper (Chung et al.) it was reported that astro-cytes may be important in eliminating unnecessary, weak or redun-dant synapses, suggesting a large role in learning and memory.

Winter 2014

10

Continued on page 11

Continued from page 9Benzoate for Negative Symptoms?A 52-subject randomized, double-blind, placebo-controlled study at two medical centers (JAMA Psychiatry, Lane et al.), found that 1 gram of benzoate daily over 6 weeks resulted in a 21% improvement in PANSS total score with effect size range of 1.16-1.69 in patients with chronic schizophrenia.

Topiramate for Cocaine Addiction?Also appearing in JAMA Psychiatry (Johnson et al.), a double-blind, randomized, placebo-controlled 12 week trial of 142 cocaine-depen-dent adults found that topiramate, at 300 mg/d in weeks 6 to 12 was associated with more nonuse days and greater likelihood of urinary cocaine-free weeks than placebo.

Breath Test for THC:In a study published in Clinical Chemistry, online, Himes et al. tested the ability to detect Δ9-Tetrahydrocannabinol (THC), 11-nor-9-car-boxy-THC (THCCOOH), and cannabinol (CBN) in the breath of mari-juana smokers. Researchers found that “THC was the major cannabi-noid in breath; no sample contained THCCOOH and only 1 contained CBN. Among chronic smokers (n = 13), all breath samples were positive for THC at 0.89 h, 76.9% at 1.38 h, and 53.8% at 2.38 h, and only 1 sample was positive at 4.2 h after smoking. Among occasional smokers (n = 11), 90.9% of breath samples were THC-positive at 0.95 h and 63.6% at 1.49 h. One occasional smoker had no detectable THC.” With increasing state-by-state legalization, drugged driving is an increasing concern, and this method may allow for detection of recent use in roadside testing. Exercise for Sexual SE?Lorenz and Meston published an article in Depression and Anxiety in which they explored the effects of exercise on sexual function in 52 women suffering from sexual side effects of antidepressants. They found that: “Exercise immediately prior to sexual activity significantly improved sexual desire and, for women with sexual dysfunction at baseline, global sexual function. Scheduling regular sexual activity significantly improved orgasm function; exercise did not increase this benefit. Neither regular sexual activity nor exercise significantly changed sexual satisfaction.”

#9 of the PHQ-9:Electronic records evaluation of the PHQ-9, following 84,418 outpa-tients over age 13 who completed 207,265 questionnaires between 2007 and 2011, were associated with 709 suicide attempts and 46 deaths. The results were published in Psychiatric Services (Simon et al.) with the conclusion that “Response to item 9 of the PHQ-9 for depression identified outpatients at increased risk of suicide attempt or death. This excess risk emerged over several days and continued to grow for several months, indicating that suicidal ideation was an enduring vulnerability rather than a short-term crisis.” Lilly Halts Edivoxetine:After not meeting the primary endpoint in Phase III clinical studies, Eli Lilly & Co. reported that it would not further develop its edivoxetine adjunctive treatment for depression. According to the Wall Street Journal (Mason, 12/5/13) the decision caused the company to cut its fourth-quarter earnings estimate.

Head Trauma --> Worse Alzheimer’s?A study by Mielke et al. (Neurology, 2013) found that, among 141 patients with mild cognitive impairment, a history of head trauma with at least momentary loss of consciousness by self report was associ-ated with increased amyloid deposition as measured using Pittsburgh compound B (PiB)-PET, fluorodeoxyglucose-PET. Among the 448

cognitively normal participants, there was no difference in neuroimag-ing measures between those with and without history of head trauma.

Eternal Sunshine?In a study seemingly straight out of cinema, Nature Neuroscience published a report that ECT was used to erase unwanted memories. The study abstract from Kroes et al. read: “Despite accumulating evidence for a reconsolidation process in animals, support in humans, especially for episodic memory, is limited. Using a within-subjects manipulation, we found that a single application of electroconvul-sive therapy following memory reactivation in patients with unipolar depression disrupted reactivated, but not non-reactivated, memories for an emotional episode in a time-dependent manner. Our results provide evidence for reconsolidation of emotional episodic memories in humans.”

Anxiety --> Stroke?In a prospective study of 6019 individuals followed for 16.29±4.75 years, 419 incident stroke cases were identified and reviewed. The study (Lambiase MJ et al., Stroke, 2013) found that “reporting more anxiety symptoms at baseline was associated with increased risk of incident stroke after adjusting for standard biological and behavioral cardiovascular risk factors (hazard ratio, 1.14; 95% confidence interval, 1.03-1.25). Findings persisted when additionally controlling for depression. Exploratory analyses considering the role of potential confounding versus pathway variables suggested that behavioral factors may be a key pathway linking anxiety to stroke risk.

Neuroprotective Lithium?The Pscyhiatric Times (Kaplan, 2013) recently reported on the work of Nunes et al (Br J Psychiatry, 2007) and Kessing et al (Bipolar Dis-ord. 2010) which showed considerable protection against dementia apparently conferred by lithium in patients treated for bipolar affective disorder. Methylphenidate and Priapism:The FDA released a warning that methylphenidate use in males may cause prolonged and sometimes painful erections. Glaxo Bows out of MD Payments:According to the New York Times (Katie Thomas, 12/16/13) the British drug maker GlaxoSmithKline has decided it will no longer pay doctors to promote its products and will stop coupling compensation of sales representatives to the number of prescriptions doctors write. Maternal SSRI use ≠ Autism:The New England Journal of Medicine published the research of Hviid et al. (12/19/2013) which evaluated 626,875 births and 5,057,282 person-years of follow-up, identifying 3892 cases of autism spectrum disorder. 52 cases involved children born to women who were ex-posed to SSRIs during their pregnancy. The authors wrote: “As com-pared with no use of SSRIs both before and during pregnancy, use during pregnancy was not associated with a significantly increased risk of autism spectrum disorders (fully adjusted rate ratio, 1.20; 95% confidence interval [CI], 0.90 to 1.61). Among women who received SSRIs before pregnancy but not during pregnancy, the corresponding fully adjusted rate ratio was 1.46 (95% CI, 1.17 to 1.81).”

Vitamin E Slows Dementia?In a three way clinical trial of over 600 patients, ingestion of a daily 2000 IU of alpha tocopherol outperformed 20 mg daily of meman-tine in comparison to placebo (Dysken et al., JAMA, 2013), showing “ADCS-ADL Inventory scores declined by 3.15 units (95% CI, 0.92 to 5.39; adjusted P = .03) less in the alpha tocopherol group com-pared with the placebo group. In the memantine group, these scores

Winter 2014

11

Continued from page 10declined 1.98 units less (95% CI, −0.24 to 4.20; adjusted P = .40) than the placebo group’s decline.”

Cholesterol and Alzheimer’s Risk:In a study of 74 individuals published on line through JAMA Neurology (Reed et al.) the authors “assayed total serum cholesterol, high-densi-ty lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and cerebral Aβ, measured with carbon C11–labeled Pitts-burgh Compound B (PIB) positron emission tomography.” The authors found that “higher LDL-C and lower HDL-C levels were both associ-ated with a higher PIB index.” As deposition of cerebral β-amyloid (Aβ) seems to be a key initiating event in Alzheimer disease (AD), the authors concluded that: “Elevated cerebral Aβ level was associ-ated with cholesterol fractions in a pattern analogous to that found in coronary artery disease. This finding, in living humans, is consistent with prior autopsy reports, epidemiologic findings, and animal and in vitro work, suggesting an important role for cholesterol in Aβ process-ing. Because cholesterol levels are modifiable, understanding their link to Aβ deposition could potentially and eventually have an effect on retarding the pathologic cascade of AD.”

Sleep Deprivation = Brain Injury?In a study published in Sleep (Christian et al., 2013) the neuron-specific enolase (NSE) and S100 calcium binding protein B (S-100B) of 15 adult males were measured after a full night of sleep and also after total sleep deprivation. Their reported results: “TSD increased morning serum levels of NSE (P = 0.002) and S-100B (P = 0.02) by approximately 20%, compared with values obtained after a night of sleep. In contrast, the ratio of Aβ peptides 1-42 to 1-40 did not differ between the sleep interventions.” The authors concluded that future studies must elucidate whether this is a reflection of brain injury sec-ondary to sleep deprivation or whether it reflects impaired blood brain barrier function.

MENTAL HEALTH IN THE POPULAR PRESS:

Popular Sports Supplement Contains Methamphetamine Analog:The 10/14/13 AMA Morning Rounds newsletter cited multiple news sources who reported that the popular sports supplement Craze appears to be “secretly spiked with a chemical similar to methamphet-amine that appears to have its origins as an illicit designer recre-ational drug.”

Testosterone Gels for Contrived Illness?The New York Times (10/16, Rosenthal) reported on the $2 billion American sales last year of testosterone gels, citing physicians con-cerns for side effects and lack of benefit for many.

Sleep = Cerebral Trash Pick-up Schedule?Many news outlets reported on a study appearing in Science on 10/18/2013 (Xie et al) which found that neurons appear to shrink during sleep, increasing interstitial space by up to 60%, accelerat-ing clearance of beta-amyloid, resulting in the speculation that the restorative benefit of sleep may be a “consequence of the enhanced removal of potentially neurotoxic waste products that accumulate in the awake central nervous system.”

Exercise Improves Grades:The AMA Morning Rounds newsletter reported on 10/22/2013: “Bloomberg News (10/22, Von Schaper, 1.91M) reports on a study published in the British Journal of Sports Medicine that found teens’ exam results were improved with regular exercise. According to the study, “the more children exercised at age 11, the better they did at school at English, math and science, not only at 11, but also at 13 and at 15 to 16,” with increases seen “for every extra 17 minutes of exer-

cise for boys and every 12 minutes for girls.” The researchers posit that 60 minutes of daily activity could increase student test scores by an entire grade.”

Depression ≠ Cancer:According to research published in the American Journal of Epide-miology, analyzing data from more than 14,000 individuals over 15 years, and reported in the AMA Morning Rounds of 10/25/13, depres-sion may not increase an individual’s risk of developing cancer.

Opioids in Veterans with PTSD:According to the AMA Morning report of 11/11/13: “On its front page, the Wall Street Journal (11/11, A1, Catan, Subscription Publication, 5.91M) reports that in 2012, the Veterans Health Administration treated some 50,000 veterans for problems tied to prescription opioid use. Since 1999, the VA has logged a 287 percent increase in the number of prescriptions for opioid painkillers it has issued, accord-ing to data the Wall Street Journal obtained as a result of an open-records request. What’s more, a recent study found that veterans ap-pear to have an accidental overdose rate nearly two times that of the general US population, with opioid painkillers being the number one medication involved. The Journal points out that many veterans with post-traumatic stress disorder (PTSD) who suffer from pain are also being treated with opioid painkillers and, in some cases, anti-anxiety medicines. This is problematic, because veterans with PTSD may have an increased risk for addiction. The article describes the story of injured PTSD patient Timothy Fazio, who has overdosed on opioid painkillers several times.”

Gun Violence Increases in PG13 Movies:According to a journal Pediatrics report (Bushman et al., 2013) gun violence has increased in cinema over the past decades. In much publicized findings, the researchers wrote that they “found that vio-lence in films has more than doubled since 1950, and gun violence in PG-13–rated films has more than tripled since 1985. When the PG-13 rating was introduced, these films contained about as much gun violence as G (general audiences) and PG (parental guidance sug-gested for young children) films. Since 2009, PG-13–rated films have contained as much or more violence as R-rated films (age 17+) films.”

Over the Counter Speed?USA Today (Alison Young, 11/18/13) ran an article on a publication appearing in the Journal of Pharmaceutical and Biomedical Analysis (Pawar et al., 2013) which found β-Methylphenethylamine, a non-natural amphetamine-like compound, in 9 of 21 dietary supplements tested.

Increase in ADHD Burden:Many news sources wrote about the increasing trend in diagnosis of ADHD in the United States. An article published in the Journal of the American Academy of Child & Adolescent Psychiatry (Visser et al.) concluded that “approximately 2 million more U.S. children/adoles-cents aged 4 to 17 years had been diagnosed with ADHD in 2011, compared to 2003. More than two-thirds of those with current ADHD were taking medication for treatment in 2011.”

Depression and Insomnia:The New York Times (11/24) ran an article regarding the possible bi-directional relationship between insomnia and depression, report-ing on a small study which showed dramatic improvements in both through brief cognitive behavioral therapy intervention focused on sleep.

Post-ICU Syndrome:The Wall Street Journal (Landro, 11/25) reported on the approximate

Continued on page 12

Winter 2014

12

80% of ICU survivors who show some form of cognitive or brain dysfunction, along with PTSD symptoms, depression, fatigue and prolonged muscle weakness.

New York Times Examines ADHD:Placed on the front page (12/15, Schwarz) the New York Times reported on how aggressive pharmaceutical marketing of stimulants has correlated with a tremendous increase in diagnosis of ADHD and in pharmaceutical sales of related treatments, suggesting over-diag-nosis along with minimization of side effects of treatments.

Landmark ADHD Study QuestionedIn a continuing series on ADHD, the New York Times (12/30, A11, Schwarz) published an article reporting on how many of the original authors involved in the Multimodal Treatment Study of Children with A.D.H.D. as having “oversold the benefits” of stimulants in compari-son to behavioral strategies. The article stated that several of the researchers have given interviews in which they said: “The study was structured to emphasize the reduction of impulsivity and inattention symptoms, for which medication is designed to deliver quick results”.

MENTAL HEALTH POLICY:

Mental Health Parity Rule:On 11/8/2013 the Department of Health and Human Services, the De-partment of Labor, and the Treasury, issued a final rule on the Mental Health Parity and Addiction Equity Act of 2008 intended to ensure equal benefits for those suffering from mental illness. The rule will in-crease parity between mental health/substance use disorder benefits and medical/surgical benefits in group and individual health plans.

Tracking Devices in Autism?On 11/4/13 (Siemaszko) The New York Daily News reported on Sena-tor Chuck Schumer’s proposal that the government expand a vol-untary program offered to those with Alzheimer’s disease to provide tracking devices to be worn by autistic children in the event of running away. This proposal came in response to a month-long disappear-ance of a 14 year old from Long Island City, Queens.

NC to Improve MH Access:According to the AMA Morning Rounds: “The AP (11/8, Biesecker, 2.88M) reports that yesterday, the Administration of North Carolina Gov. Pat McCrory (R) made a pledge to fix the state’s “struggling system for treating people with chronic mental illness and substance abuse, but provided few details about how it would fix the problems.” At a news conference, North Carolina Department of Health and Hu-man Services Secretary Aldona Wos announced “a new Crisis Solu-tions Initiative to include government officials, health care profession-als, law enforcement and patient advocates.” Wos explained that “the new panel will study local programs around the state that are having the most success getting people help.””

Physician Apologies Protected in Pennsylvania:According to the AMA Wire on 10/31/13: “A new medical liability reform in the Keystone State should bring a breath of fresh air to physicians and patients alike as doctors will be able to apologize for unfavorable medical outcomes without worry that those statements or gestures will be used against them in court.”

New York Initiative on First Break Psychosis:According to the AMA Morning Rounds Newsletter, 10/14/13, “The New York Post (10/14, Buiso, 1.4M) reports the city Department of Health wants “hospitals to hand over information on patients admitted for a first psychotic episode,” as part of a program “aimed at deliver-ing care to mentally ill people who might endanger themselves and others.” The program would seek data on patients ages 18 to 30 “within 24 hours of their admission.” The city reach out to patients “to

participate in a ‘linkage to care’ program,” under which the city will “remain in contact and make sure” the patients receive specialized care in area mental-health clinics.”

Improved Mental Health Training Indicated for Law Enforcement:On its front page, the Wall Street Journal (10/23, Fields, Subscription Publication, 5.91M) reports a noticeable uptick over the past decade in the number of fatal confrontations between police officers and people with severe mental illnesses. A small number of those cases are known as “suicide by cop” in which police officers are intention-ally provoked to react with lethal force. In other cases, police officers with poor or no mental health training misread a situation with deadly results. Some police departments are now sending officers to special crisis-intervention training and teaching them how to respond to situ-ations involving people with severe mental illnesses, emphasizing communication and use of non-lethal weapons.

Biden Meets with Newtown Families:According to the 12/11/13 AMA Morning Report: “Several high profile media outlets, including a network news broadcast and the websites for multiple national newspapers, cover Vice President

Joe Biden’s announcement on the first anniversary of the Sandy Hook shootings that the Federal government will provide an additional $100 million for mental health services. The funding comes from the Afford-able Care Act and the Department of Agriculture.”

Rep. Murphy Introduces Mental Health Bill:The Wall Street Journal (12/13, Fields) reported that Representative Tim Murphy (R-PA and a clinical psychologist), introduced the “Help-ing Families in Mental Health Crisis Act of 2013.” The bill proposes creation of a new position of assistant secretary for mental-health and substance-use disorders within the Department of Health and Hu-man Services. The position would be charged with examination of all aspects of mental healthcare funding as well as treatment.

Governor Walker Signs Informed Consent Bill:In a move praised by the Wisconsin Medical Society, the governor signed Assembly Bill 139, clarifying informed consent responsibilities in response to the 2012 Wisconsin Supreme Court decision in Jandre v. Wisconsin Injured Patients and Families Compensation Fund. The bill establishes a “reasonable physician” standard for what information should be provided to patients, whereas the court decision created a potential “hindsight 20/20” standard, subjecting a physician’s missed diagnosis to absolute liability, whether or not the physician was neg-ligent. It also clearly states that a physician need not provide patient information regarding alternate treatments for conditions the physician has already ruled out.

Experiment in Raleigh, N.C.:Faced with increasing costs for the mentally ill, the New York Times (Creswell, 12/25/2013) reported on an experiment taking place in Ra-leigh, North Carolina, where overhaul of mental health treatment and loss of psychiatric beds has increased emergency room visits for the mentally ill. Instead of being taken to an emergency room, police now bring psychiatric patients to a commercial psychiatric facility, such as Holy Hill Hospital. The reporter wrote: “Nationally, more than 6.4 million visits to emergency rooms in 2010, or about 5 percent of total visits, involved patients whose primary diagnosis was a mental health condition or substance abuse. That is up 28 percent from just four years earlier, according to the latest figures available from the Agency for Healthcare Research and Quality in Rockville, MD. By one federal estimate, spending by general hospitals to care for these patients is expected to nearly double to $38.5 billion in 2014, from $20.3 billion in 2003.” According to the article, the experiment is being watched closely by other communities grappling with similar issues.

Continued from page 11

Winter 2014

13

Eligible APA members can use their member login to cast their vote in the 2014 APA National Elections here. Candidate

information can be found on the electronic ballot and the Elections webpage.

Draft APA practice guidelines on the psychiatric evaluation of adults are now available for review by all APA members. Down-loadable PDF versions of the drafts are available on the APA web-site at www.psychiatry.org/practice/clinical-practice-guidelines/review-draft-guidelines. The deadline to comment is February 5th, 2014. Comments submitted to guidelines@psych.org are preferred. Instructions for commenting are provided on the page linked above.

The guidelines address the following topics, in the context of an initial psychiatric evaluation: assessment of suicide risk, as-sessment of risk of aggressive behaviors, cultural assessment, assessment of substance use, review of psychiatric symptoms and treatment history, assessment of medical health, involving the patient in treatment decision-making, documentation, and use of quantitative measures.

Vote in the 2014 APA National Elections!

Draft APA practice guidelines on the psychiatric evaluation of adults

News from the APANovember 2013Mental Health Parity: Final RuleThe Obama Administration took a significant step toward undo-ing barriers to care for people with mental illness by issuing a Final Rule for the Mental Health Parity Act. See comments from APA President Jeffrey Lieberman, MD and look for further analysis from APA soon. In many circumstances, federal law re-quires equal insurance coverage of medical/surgical services and mental health services. Learn more!

A Healthy Minds Minute with former Congressman Patrick KennedyThe second in a series of PSAs intended to raise awareness about mental health focuses on supporting military veterans and their families. Learn more (More PSAs & videos from APAHealthyMinds.)

APA President Jeffrey Lieberman, MD Video SeriesIn the sixth video series, APA President, Jeffrey Lieber-man, MD addresses advances in early intervention for psychosis. Other videos examine key issues in psychia-try and mental health care including collaborative care, health care reform, federal funding, and more.

Minority Fellowships ProgramThe Minority Fellowship program is an innovative, comprehensive and coordinated training and leadership development program designed to increase the number of professionals in psychiatry who are committed to the mental health needs of minority patients and their communities. The three groups of MFP fellows are: Substance Abuse and Mental Health Services Administration (SAMHSA) fellows, Substance Abuse fellows, and the Diversity Leadership fellows. Click here for more details. The deadline to apply is January 30.

I Will Listen CampaignThe New York City Metro Chapter of the National Al-liance on Mental Illness (NAMI - NYC) has launched a new anti-stigma campaign called I Will Listen. The campaign encourages people to post their own

videos about mental illness, and to close with the signoff, “I will listen.” Learn more

Registration And Housing Is Now Open!Changing the Practice and Perception of Psychiatry

Join your colleagues from across the U.S. and over 50 other countries for the psychiatry event of the year! Attend this year’s 167th Annual Meeting in New York City, the cultural capital of the world, to get insight into the tools and in-depth knowledge you need to improve your patient care. The Sci-entific Program will feature a variety of innovative

sessions and inspiring courses with tracks focusing on changing the practice and perception of psychiatry

Top Reasons Why You Should Attend • Earn your annual state licensure CME credit at one

meeting! • Discover cutting-edge science and new therapies. • Learn from renowned thought leaders in the areas of

health policy & ethics. • Reconnect with your peers and expand your professiona

network. • Explore the exhibit hall for innovative treatment options

and new technologies.

View the Annual Meeting Information Guide for more information.

Register now and reserve your hotel today! Go here for Group Registration.

WANT TO KNOW MORE ABOUT INTEGRATED CARE?• Subscribe to Integrated Care News Notes (ICNN), a weekly

newsletter focused on integrated care and delivery system innovations policy.

• Access the latest Integrated Care News Notes (ICNN)• Read PsychNews on Integrated Care, including FAQs• View a short video with Dr. Howard Goldman on APA’s

Healthcare Reform Workgroup

The Wisconsin Psychiatrist

14

Superior protection provided by Allied World Assurance Company rated “A” (Excellent) by A.M. Best Company

Access to a Risk Management Attorney 24 hours daily

Individual Customer Service provided by our team of underwriters

Telepsychiatry, ECT coverage and Forensic Psychiatric Services are included

Many Discounts including Claims-Free, New Business and No Surcharge for claims *Great Low Rates

Years in the previous APA-endorsed Psychiatry program count towards tail coverage on our policy

Fire Damage Legal Liability and Medical Payment coverage includedInterest-Free Quarterly Payments / Credit Cards accepted

* Subject to State Approval

Join your colleagues who have chosen to be represented by our professional team and our program which is endorsed by the two most prominent associations in yourprofession - the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.

Paid Advertisement

Winter 2014

15

Make a difference. Join our award-winning team.

At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 11 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, flexible schedules and competitive benefits in an environment where passionate people thrive and excel.

Contact Brooke Eilbert, Physician Recruitment Services1-800-248-4921 (toll free) | Brooke.Eilbert@allina.com

Apply today at allinahealth.org/careers

16695 0613 ©2013 ALLINA HEALTH SYSTEM ® A TRADEMARK OF ALLINA HEALTH SYSTEM. EOE/AA

We are seeking Adult, Child/Adolescent and Geriatric Psychiatrists to join our Psychiatry team in Minnesota.

Paid Advertisement

Wisconsin Psychiatric Association563 Carter Court, Suite BKimberly, WI 54136

A District Branch of the American Psychiatric Association

Personalized Treatments for Anxiety and Mood Disorders

March 27–30, 2014 | Chicago Marriott Downtown www.adaa.org/conference

Engage, Practice, Research, Network

“The ADAA Annual Conference is where clinicians and researchers from multiple disciplines who focus on anxiety and mood disorders can engage. There is

no other meeting in this area focusing on children and adults that provides so many opportunities to earn CME credits.”

Mark Pollack, MD, ADAA President Chair of Psychiatry, Rush University Medical Center, Chicago, Illinois

Anxiety and Depression Association of America www.adaa.org

Paid Advertisement

Wisconsin Psychiatric Association

2014 Annual Conference March 6-8, 2014

The American Club, Kohler Registration Form

Visit www.thewpa.org or scan with your smart device and register online today!

*Name (to appear on name badge):

*Highest degree(s) (to appear on name badge):

*Company/Institution:

*Address:

*City/State/Zip:

Phone: *Email Address:

Please indicate any special dietary needs: *Required for CME credits

CONFERENCE REGISTRATION (check one) $325 WPA Member: Thursday-Friday-Saturday

$250 WPA Member: Friday-Saturday Only

$400 Non-Member Healthcare Provider: Thursday, Friday, Saturday

$325 Non-Member Healthcare Provider: Friday-Saturday Only

$175 WPA Early Career Psychiatrist: Full conference

No Charge WPA Resident/Fellow: Full conference

$75 Member OR Non-Member: Thursday Dinner Program Only REGISTRATION OPTION FOR RESIDENTS & ECPs No Charge Friday Resident & Early Career Psychiatrist Dinner GUEST REGISTRATION (check all that apply) $25 Guest: Thursday Dinner (with registered attendee)

$35 Guest: Friday Luncheon (with registered attendee)

No Charge Guest: Friday Resident/ECP Dinner (with registered resident/ECP attendee) TOTAL DUE: METHOD OF PAYMENT Check (payable to WPA) Credit Card: VISA MasterCard Discover Card Number: Expiration Date: Security Code: Billing Address (if different from address above: Name on Card: Signature: Please return registration form and payment to:

Wisconsin Psychiatric Association | 563 Carter Court, Suite B | Kimberly, WI 54136 Fax: 920-882-3655 · Email: julie@badgerbay.co